Renal and Urologic Problems Ch. 46

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  1. Most common pathogen causing UTI
    E. Coli
  2. Risk Fx of UTI
    • Women
    • Pregnancy
    • Elderly
  3. Fungal and Parasitic UTI most commonly seen...
    • immunosuppressed
    • have diabetes
    • have undergone multiple courses of antibiotic therapy
  4. Pyelonephritis
    inflammation of renal parenchyma and collecting system
  5. Cystitis
    inflammation of the bladder
  6. Urethritis
    inflammation of the urethra
  7. Urosepsis
    UTI that has spread into the systemic circulation and is possible life threatening situation requiring immediate treatment. Can lead to septic shock and death in 15% of cases
  8. Uncomplicated UTI
    UTI involving only the bladder
  9. Complicated UTI
    Presence of stones, diabetes or neurological disease, pregnancy or recurrent can put patient at risk for pyelonephritis, urosepsis and renal damage
  10. Clinical manifestations of UTI
    • Dysuria
    • Frequent urination - > 8 TIMES IN 24 HOURS
    • Urgency
    • Suprapubic discomfort
    • Hematuria or sediment producing a cloudy appearance
    • Incontinence
    • Nocturia
    • Nocturnal enuresis
  11. Lower UTI Symptoms
    • Hesitancy
    • Diminished
    • Intermittency
    • Post void dribbling
    • Urinary retention of incomplete urination
  12. Diagnosis of UTI
    • Dipstick to identify presence of nitrites,
    • White blood cells, and leukocyte esterase (enzyme present in WBCs indicating pyuria
    • Above findings confirmed by microscopic urinalysis
    • Urine culture and sensitivity – clean catch, mid stream urine specimen is required – send to lab immediately. Culture must be done within 24 hours of collection (urine must be refrigerated is test delayed)
    • Catheterized specimen provides most accurate clean catch
  13. If obstruction of urinary tract suspected may do...
    • Intravenous pyelogram (IVP)
    • abdominal CT
  14. Treatment of Uncomplicated UTI
    • Trimethoprim-sulfamethoxazole (Bactrim, Septra
    • Nitrofurantoin (Macrodantin, Macrobid)
    • Adequate fluid intake (6 8 oz glasses daily)
  15. Patient education regarding use of Nitrofurantoin (Macrodantin, Macrobid)
    • Avoid sun exposure
    • Report fever, chills, cough, chest pain dyspnea – May indicate pulmonary fibrosis
    • Report numbness, tingling of fingers or toes – May indicate neuropathies
  16. Care for Complicated UTI
    • Imaging studies
    • Culture/Sensitivity guided antibiotic therapy (ampicillin, amoxicillin, first generation cephalosporins
  17. Bladder Irritants to avoid for UTI pt
    • caffeine
    • alcohol
    • citrus juices
    • chocolate
    • spiced foods
  18. Acute Pylenephritis Onset
    • Colonization and infection of the lower urinary tract – E.coli, Proteus, Klebsiella or Enterobacter
    • Preexisting factor such as reflux, obstruction (BPH), stricture or urinary stone often exists
    • Long term use of catheters is common cause
    • Recurrent pyelonephritis especially in presence of obstructive abnormality can lead to kidney damage and condition called chronic pyelonephritis
  19. Clinical Manifestations of Acute Pylenephritis
    • Vary from mild fatigue to sudden onset of chills, fever, vomiting, malaise, flank pain as well as symptoms including:
    • Dysuria, urgency, frequency, CVA tenderness (costovertebral)
    • Urinalysis : pyuria, bacteriuria and varying degrees of hematuria, WBC casts indicating involvement of the renal parenchyma, leukocytosis with shift to the left and increase in bands
  20. Diagnosis of Acute Pylonephritis
    • CBC with differential: WBC casts may be found; leukocytosis w/ shift to the left
    • Urinalysis: pyuria, bacteriuria, varying degrees of hematuria
    • Urine Culture and Sensitivity
    • Blood Cultures for more severely ill and hospitalized
    • IVP or CT requiring contrast may not be done because of impaired renal function
    • Ultrasound of urinary system: identify anatomic abnormalities, presence of obstructing stone
  21. Care of Acute Pyelonephritis
    • Outpatient management – antibiotics 14-21 days
    • Broad spectrum antibiotics initially (ampicillin, vancomycin) with more specific antibiotics based on culture/sensitivity (bactrim, septra)
    • Adequate fluid intake
    • Nonsteroidal antinflammatories or antipyretics
    • Nursing Interventions same as for UTI
  22. Glomerulonephritis
    • Immunologic processes involving the urinary track predominately affecting the renal glomerulus
    • Affects both kidneys and is the third leading cause of renal failure in the US
    • Characterized by an accumulation of antigen, antibody and complement in the glomeruli resulting in tissue injury
    • Acute poststreptococcal glomerulonephritis – 5-21 days post strep infection (general body edema, hypertension, oliguria, hematuria, smoky or rusty colored urine – all occur as a result of decreased glomerular filtration)
  23. Manifestations of Glomerulonephritis
    • Hematuria
    • Urinary excretion of various formed elements including RBCs, WBCs and Casts.
    • Proteinuria
    • Elevated BUN, Creatinine
  24. Diagnosis of Glomerulonephritis
    • Urinalysis
    • CBC with Differential (Elevated urea levels in CBC = Renal insufficiency or Failure)
    • BUN, serum creatinine and albumin (Elevated)
    • Complement levels (small proteins synthesized by liver that when activated enhance immune response) and ASO (common antibody found upon exposure to Strep infection) titer
    • Renal Biopsy if indicated
  25. Care of Glomerulonephritis
    • Rest
    • Sodium and fluid restriction
    • Diuretics
    • Antihypertensive therapy as indicated
    • Adjustment of dietary protein intake to level proteinuria and uremia (Retention of urea in blood indicating renal insufficiency or failure)
  26. Goodpasture Syndrome
    • Autoimmune Disease
    • Very Rare- Mostly associated w/ young male smokers
    • More Systemic Symptoms (Pulmonary: cough, SOB, hemoptysis, crackles, rhonchi; Renal: hematuria, weakness, pallor, anemia, and renal failure)
    • Chronic, NOT CURABLE
    • Treat w/ corticosteroids, immunosuppressive drugs, plasma pheresis, and dialysis
  27. Nephrotic Syndrome
    • Glomerulus becomes excessively permeable to plasma protein causing proteinuria that leads to low plasma albumin and tissue edema
    • Severely increased proteine in urine
    • In adults, 1/3 of patients with nephrotic syndrome will have systemic disease such as diabetes or systemic lupus
  28. Clinical Manifestations of Nephrotic Syndrome
    • Peripheral edema, massive proteinuria, hypertension, hyperlipidemia (low plasma protein levels stimulate lipoprotein synthesis by liver), hypoalbuminemia
    • Decreased serum albumin, decreased total serum protein and elevated serum cholesterol and LDLs plus elevated triglycerides
    • Ascites and anasarca develop if there is severe hypoalbuminemia
  29. Management of Nephrotic Syndrome
    • Based on Symptom Management (Mostly for edema)
    • ACE Inhibitors: edema
    • NSAIDs: decrease inflammatory process
    • Low Sodium (2-3 gm) diet: Key for managing edema
    • Low to Moderate Protein diet (0.5-0.6 g/kg/day)
    • Thiazide or Loop Diuretics
  30. Nursing Interventions for Nephrotic Syndrome
    • Assessment and management of edema is most important aspect
    • Daily Weight
    • I/O
    • Measure abdominal girth daily (fluid gained or loss)
    • Cleanse edematous skin gently, avoid injury and monitor effectiveness of diuretic therapy (monitor potassium levels)
    • Patient at risk for malnutrition because of excessive protein loss – small frequent feedings (albumin & prealbumin decreased in these patients)
    • Implement measures to avoid infections
  31. Urinary Tract Calculi
    • Nephrolithiasis ( kidney stone disease more common in males)
    • May be found in various locations in the urinary tract
  32. Risk Fx of Urinary Tract Calculi
    • Abnormalities that result in increased urine levels of calcium, oxaturic acid, uric acid and citric acid
    • Warm climates that cause increased fluid loss, low urine volume and increased concentration of urine
    • Large intake of protein that increased uric acid excretion, tea or fruit juices that elevate urinary oxalate
    • Large intake of calcium
    • Low fluid intake
    • Family history, gout, renal acidosis
    • Sedentary occupation, immobility
  33. Causes of Urinary Tract Calculi
    • Calcium Phosphate
    • Calcium Oxalate
    • Uric Acid
    • Cystine
    • Struvite (magnesium ammonium phosphate)
    • Stone composition may be mixed although calcium stones are the most common
  34. Symptoms of Urinary Tract Calculi
    • Symptoms occur when urinary flow is obstructed
    • Symptoms: abdominal or flank pain hematuria and renal colic (occurs in response to increased ureteral peristalsis in response to the passage of small stones along ureter (spasmodic pain)
  35. Diagnosis of Urinary Tract Calculi
    • Urinalysis
    • Urine culture
    • CT Scan: differentiate nonopaque stone from tumor
    • IVP (Intravenous Pyelogram): localize the degree and site of obstruction or to confirm presence of a radiolucent stone; should NOT be performed on pt w/ renal failure
    • Ultrasound
    • Cystoscopy
  36. Treatment of Urinary Tract Calculi
    • Manage acute attack- most pass spontaneosly; >4 mm unlikely to pass
    • Manage symptoms of:
    • Pain
    • Infection
    • F/E balance/hydration to avoid hydration
    • Evaluation of cause of stones
  37. Cystoscopy
    done to remove small stones from the bladder
  38. Cystoscopic lithotripsy
    used for large stones – stones are pulverized prior to removal
  39. Flexible ureteroscopes
    used to remove stones from renal pelvis and upper urinary tract
  40. Percutaneous nephrolithotomy
    nephroscope inserted through sinus tract from the skin into the kidney pelvis – stones can also be fragmented prior to removal (minor surgical procedure)
  41. Lithotripsy
    • Eliminates stones from the urinary tract.
    • Various types of lithotripsy procedures
    • Some required anesthesia
    • Hematuria is common after lithotripsy procedures
    • Some require the placement of a self retaining ureteral stent which is generally removed within 2 weeks
  42. Nutritional Therapy for pt w/ Urinary Tract Calculi
    • Adequate fluids to avoid dehydration
    • Excessive fluid intake has not been shown to facilitate spontaneous passage and may increase the pain or renal colic
    • Following an episode of urolithiasis, a high fluid intake ( 3000 ml/day) is recommended to produce a urine output of at least 2L/day)
    • Avoid high intake of colas, coffee and tea
    • High calcium intake may lower the risk of reducing urinary excretion of oxalate, a common factor in many stones
    • Low sodium diet is recommended to decrease calcium excretion in the urine
  43. Cause of Stone Formation helps determine dietary interventions
    • Purine rich foods: sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads.
    • Moderate: most meats, salmon, crab, veal
    • Calcium: Dairy products, lentils, fish with ones, dried fruits, nuts, chocolate
    • Oxalate: spinach, asparagus, cabbage, tomatoes, beets, nuts chocolate, cocoa, tea
Card Set:
Renal and Urologic Problems Ch. 46
2011-11-10 06:26:17
Massey Test

Massey Test 4
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